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Vol. XXIV.

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No. 9.

NASHVILLE, SEPTEMBER. 1902.

Original Communications.

FACTS VS. FALLACIES IN THE PRACTICE OF RECTAL DISEASES.*

BY A. B. COOKE, A.M., M.D.,

Professor of Anatomy and Clinical Professor of Proctology, Medical Department Vanderbilt University; Fellow American Proctologic Society; Ex-President Nashvile Academy of Medicine, etc.

Properly speaking, Mr. President and gentlemen, no man is entitled to an opinion as to the existence or non-existence of a gross anatomic structure. The facts of anatomy are as definite and indisputable as any other facts within the realm of matter, and as such they permit of demonstration to every mind which is open to the truth and capable of apprehending it. I rejoice to believe that the science of medicine possesses at least this one element of certainty and that no man's opinion or denial can change or modify it.

*Read before the Southern Kentucky Medical Association, Bowling Green, October 24, 1901.

In the pursuit of truth the "views" of individuals upon a controverted point are to be valued, not for the source from which they emanate, but wholly and solely in proportion to the weight of evidence by which they are sustained. On any other basis all scientific discussion would be fruitless and the time devoted to it worse than wasted.

The semilunar rectal valves, to the consideration of which this paper is limited, were first described by Mr. John Houston, of Dublin, in 1830. In a classical paper published in Vol. V., p. 130 of the Dublin Hospital reports, he described these structures with a clearness and accuracy of detail which the passage of nearly three-quarters of a century has only served to verify and emphasize. But, as has been the case in many other instances, which might be cited, the verification of this description did not follow at once nor without a struggle. In fact its correctness is even yet disputed by a limited few whose opposition is chiefly notable for its dogmatic tone and whose influence has done much to obscure and suppress the truth.

It would scarcely be pertinent to the purposes of this paper to enter into an exhaustive review of the literature of the rectal valves. But the matter is one of sufficient scientific interest to warrant a brief allusion to the more important views which have been entertained upon the subject.

At about the same time that Houston described the semilunar valves the celebrated French surgeon, M. Nelaton, described what he designated the "third sphincter ani muscle," assigning to it a location corresponding with noteworthy exactness to that of one of Houston's valves. From this time on for many years the subject remained in a state of almost hopeless confusion. Velpeau (1837), Kohlrausch (1854), Gosselin (1854), Hyrtl (1857), Henle (1873), endorsed with varying qualifications and designations Nelaton's idea of a third sphincter. O'Beirne (1833) and Bushe (1837) confined their attentions to Houston's valves, the existence of which they fiercely disputed. Boden. hamer (1870) utterly discredited the presence of such structures as "veritable valves" in the normal rectum. Sappey (1874) denied the existence of either the semilunar valves or the third sphincter.

The first reliable corroborative evidence as to the correctness

of Houston's views was furnished by two American investigators, Chadwick (1878) and Otis, of Boston, (1887), and incidentally both record their convictions that no such structure as a third sphincter muscle is present in the normal rectum. The observations of both these gentlemen served to positively confirm the views originally expressed by Houston upon the anatomic point in question.

To Martin, of Cleveland, however, is due the present revival of interest in the subject in this country and to him more than to any other investigator belongs credit for original work in this field. His first contribution upon the valves appeared in Mathews' Medical Quarterly for October, 1896, under the title "New Evidence that the Rectal Valve is an Anatomical Fact," in which the subject was discussed in a notably fair and scientific spirit, and his methods of investigation fully set forth. Since that time he has written extensively upon the subject, and many other observers have added their testimony as to the correctness and accuracy of his work.

In order to bring the subject under discussion strictly up-todate and be in possession of the testimony of reliable clinical observers, on March 4th, 1901, I mailed a copy of the following questions to each of sixteen gentlemen whose authority on any subject of which they undertake to speak cannot be gainsaid. The list embraced the entire membership of the American Proctologic Society, with the exception of myself and one other member, and in addition two distingushed specialists in gynecology and abdominal surgery:

1. When you have occasion to explore the movable rectum do you invariably find the rectal valves present?

2. Do you regard them as definite anatomic structures?
3. What is your opinion as to their pathogenetic signifi-

cance?

Fifteen of the sixteen responded. Of these fifteen only one failed to declare himself in positive and unequivocal terms, he declining on the ground that he had not yet satisfied himself and preferred not to go on record at that time. Omitting the third question as irrelevant to the present discussion, analysis of the remaining fourteen replies gives the following interesting results: Question 1. "Do you invariably find the rectal valves

present?" Twelve affirmative answers, one negative, qualified by the explanation that the writer frequently detected them; and only one straight negative.

Question 2. "Do you regard them as definite anatomic structures? Twelve affirmative answers, one doubtful and again but one negative.

It is worthy of remark that only one unqualified negative reply was made to each question and that by the same writer in both instances. I very much regret that this gentleman did not see fit to mention the method of examination employed by him. In the absence of a specific statement to the contrary we can only conclude that he has not yet familiarized himself with modern instruments and their proper use.

I take the liberty of quoting verbatim the pertinent portions of several of the replies. The originals of all have been preserved and are in my possession.

Dr. S. G. Gant, of New York, Professor of Rectal Surgery in the Postgraduate Medical School and author of a well-known text-book on the subject says:

1. Unless some disease destroying the elasticity of the rectum prevents inflation, I never fail to locate the valves."

2. "My experiments go to show that they are constant, are covered by mucous membrane, and have longitudinal and circular muscular fibres which extend well up to the edge of the projecting portion of the valve."

Dr. J. R. Pennington, Professor of Rectal Surgery in the Chicago Polyclinic, says:

1. "I have found the plicae transversalis recti invariably present."

2. It is my opinion from numerous dissections made that they are definite anatomic structures.'

Dr. W. M. Beach, of Pittsburg, Secretary of the American Proctologic Society:

1. The routine proctoscopy which I practice invariably reveals the presence of two or more rectal valves."

2. "The rectal valve has the appearance of a definite anatomic structure and microscopy supports that idea."

Dr. Howard A. Kelly, of Johns Hopkins, Baltimore, whose authority to speak on any subject connected with the anatomy of

the pelvic viscera no man will question, expresses himself as follows:

1. "The semilunar valves I always find present unless destroyed by disease."

2. "Yes, I regard them as definite, important anatomic structures."

Dr. Richard Douglas, of Nashville, formerly Professor of Gynecology and Abdominal Surgery, Medical Department Vanderbilt University:

1 "I invariably find the rectal valves if the patient is placed in the knee-chest position and the proctoscope used. I never saw these valves until I employed the proper position for rectal examination."

2 "They are present in all patients that I have examined with or without rectal symptoms and I therefore regard them as definite anatomic structures."

It is to be observed that the gentlemen above quoted each employs the proper posture and the proper instruments in his examinations of the rectal pouch. And it is well to define just here what is meant by proper posture and instruments. By the former is meant the knee-chest (not knee-elbow) position; by the latter, inflexible tubes whether denominated proctoscopes or speculums, and the head mirror. The principle involved in this method of examination is essential. Perhaps it were charitable to suppose that the few gentlemen who still doubt and deny the existence of the valves owe their attitudes on the subject to their failure to adopt it.

For the last two and a half years I have used the proctoscope constantly and habitually. During that time I have taken occasion to examine the movable rectum in some two hundred different individuals, and with the exception of those subjects in whom the gut walls had been rendered non-inflatable by disease, I have not found an instance in which the presence of the valves admitted of a question. Let me put that stronger. I do no violence to the most exacting regard for truth when I say that I have not only invariably found these structures present, but always the most conspicuous and easily discernible features in the entire rectum. So uniform has been this experience that I should not hesitate to pronounce the rectum from which they were absent abnormal to that extent.